Summary: The Ombudsmen has not found fault by a Council, an NHS Trust or a CCG with their assessment and/or consideration of continuing healthcare funding. The Ombudsmen found fault by a GP Practice in not considering fast-tracking a continuing healthcare assessment. The Practice has already accepted the fault and taken action to learn from the complaint. A retrospective continuing healthcare review which the CCG has agreed to will remedy any potential financial injustice.

The complaint

1. Mrs L complains on behalf of her late mother Mrs R. She complains about the actions of Wolverhampton City Council (the Council), The Royal Wolverhampton NHS Trust (the Trust), Wolverhampton CCG (the CCG) and Grove Medical Centre.
2. In particular, Mrs L complains there was a delay in NHS Continuing Healthcare (CHC) being put in place for Mrs R.
3. Mrs L believes the organisations collectively failed to ensure Mrs R received CHC funding at the appropriate time after she was discharged from hospital in mid-January 2017. She says this meant Mrs R incurred care fees that CHC funding should have covered.
4. As an outcome to the complaint Mrs L wants the financial contributions paid towards Mrs R’s care package from mid-January 2017 onwards reimbursing. She also wants to see that the organisations have learned from the issues raised in her complaint and have made changes as a result to prevent a recurrence.

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The Ombudsmen’s role and powers

5. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
7. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

8. I took account of the information Mrs L provided to the Ombudsmen. I made enquiries of the Council, the Trust, the CCG and the Practice and took account of the documents and comments they provided, including relevant medical and care records for Mrs R.

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What I found

9. The Department of Health’s National Framework for NHS Continuing Healthcare and NHS‑funded Nursing Care (November 2012 (Revised)) (the National Framework) was the key guidance about Continuing Healthcare at the time of the complaint. The National Framework was updated in 2018.
10. Continuing Healthcare (CHC) is a package of ongoing care arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist. The threshold for meeting the CHC Checklist is set low.
11. If the completed CHC Checklist indicates the person may be eligible for CHC, the next step is a full multidisciplinary assessment. This assessment is completed using a decision support tool (DST). The DST is a record of the relevant evidence and decision-making. The DST should be completed within 28 days of the CHC Checklist.

Fast Track Pathway

12. The Fast Track Pathway Tool must only be used when the individual has a rapidly deteriorating condition and may be entering a terminal phase.
13. The Fast Track Pathway Tool replaces the need for the Checklist and the DST to be completed. However, a Fast Track Pathway Tool can also be completed after the Checklist if it becomes apparent at that point the Fast Track criteria are met.
14. The Fast Track Pathway Tool can be used in any setting. This includes where such support is needed for individuals who are already in their own home or are in a care home and wish to remain there.
15. An ‘appropriate clinician’ should complete the Fast Track Tool. They should explain why they consider the person is eligible for fast-tracking. ‘Appropriate clinicians’ are those responsible for an individual’s diagnosis, treatment or care and who are medical practitioners (such as consultants, registrars or GPs) or registered nurses. The clinician should have an appropriate level of knowledge or experience to be able to comment on whether the individual has a rapidly deteriorating condition that may be entering a terminal phase.

Retrospective Claims

16. A person can make a claim for CHC funding after a period of care has elapsed, for example, on behalf of someone who has died. In 2012 the Department of Health introduced a single national process, to determine whether an assessment should be carried out for previously unassessed periods of care. It also introduced set timescales for people to notify the NHS that they should have been assessed for eligibility for NHS CHC funding with respect to that care.

Background

17. Mrs R had a medical history including type 2 diabetes, an auto-immune condition which affects the liver, stroke and kidney disease. On 26 October 2016 Mrs R was admitted to hospital with low sodium levels and increased drowsiness.
18. The Trust completed a CHC checklist on 17 November 2016. She did not meet the threshold for a full CHC assessment. She was discharged home on 29 November with a package of care organised by the Council. Mrs R made a financial contribution of £75.84 per week towards her care package.
19. On 4 January 2017 a social worker at the Council spoke to Mrs L to arrange the completion of a CHC checklist. This was arranged for 23 January to allow Mrs L and her sister to both be present.
20. On 13 January 2017 Mrs R went to the Emergency Department at the Trust with confusion and drowsiness. Doctors provisionally diagnosed her with non‑specific confusion/delirium. Mrs R was admitted to the Acute Medical Unit for further investigations to take place, including a CT head scan. This showed no new changes or bleeding. Mrs R was discharged home on 16 January 2017 with a plan to perform an ultrasound of her liver as an outpatient. The discharge summary notes Mrs R was stable and medically fit for discharge following senior medical review.
21. On 20 January Mrs R’s GP visited her. The records show he made referrals to gastroenterology for review and arranged blood tests and an ultrasound scan.
22. On 23 January the Council competed a CHC checklist. This indicated Mrs R needed a full assessment. The DST was completed on 15 February. The DST noted end of life care commenced with the district nursing service on 26 January. Mrs R met the criteria for CHC funding. The CCG funded care from this date.
23. Mrs R saw her GP on 16 February 2017. The GP noted Mrs R was on the end of life pathway. The GP noted Mrs R’s family agreed with this and referred her to the palliative care nurse. It also noted daily input from a local hospice.

24. Mrs R died at home on 1 March 2017.

Analysis

25. Mrs L complains about the delay in Mrs R’s CHC assessment and the award of CHC funding. She considers the CCG should backdate CHC eligibility to mid‑January 2017 as her mother was receiving end of life/palliative care.
26. Mrs R’s hospital records from her admission on 13 January do not show significant deterioration in her illness or that she needed end of life care. The records show the symptoms she presented with on admission were settled and it arranged to follow-up Mrs R as an outpatient. Mrs R had a package of care in place at home and there was no significant change to her condition. The Council had already arranged to complete a CHC Checklist for Mrs R. There was no indication for the Trust to complete or bring forward completion of a CHC checklist prior to her hospital discharge. This was in line with the National Framework and was not fault by the Trust.
27. The Council sent the positive CHC checklist it completed on 23 January to the CCG. The CCG completed the DST on 15 February. This is within the timeframe set out in the National Framework. Mrs R was not on an end of life pathway at that time. There was therefore no fault by the Council or the CCG in relation to completion of the DST.
28. The decision to fast‑track a CHC assessment has to be made by an ‘appropriate clinician’. The Council could not make this decision, but it could, where appropriate, request consideration of this from a clinician. However, as noted above, Mrs R was not on the end of life pathway. Mrs R’s GP had seen her a few days earlier and district nurses had not started end of life care at that point. I therefore do not consider it was fault that the Council did not seek consideration of a fast‑track assessment when it completed the checklist.
29. The GP’s complaint response accepted he had a limited understanding of the CHC process and fast-tracking funding requests. He said, in retrospect, he believed Mrs R met the criteria for fast-track funding when he visited on 20 January 2017.
30. The Practice acknowledged fault in failing to consider fast-track CHC funding for Mrs R. It accepted the GP should have discussed this with the family and made checks with social care or nursing staff about CHC funding. It is therefore possible, with the GP’s backing, CHC fast-track funding could have been requested before the date the CCG completed the DST.
31. The CCG has noted that although Mrs R needed palliative care, this did not necessarily mean she was nearing the end of her life. Although in hindsight it was the GP’s view Mrs R may have met the criteria for fast-track, it is not for the Ombudsmen to make this assessment.
32. In any event, the CCG has already written to Mrs L and agreed to undertake a retrospective CHC review for Mrs R. I consider such a review will establish if Mrs R was eligible for CHC funding before 15 February and will therefore remedy any potential financial injustice. Mrs L (or the executor of Mrs R’s estate) will need to provide relevant documents the CCG has already asked for to progress this review.
33. In terms of wider learning, the GP has committed to improving his understanding of CHC and fast-track process with other GPs at the Practice. I consider this addresses the systemic fault in this case.

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Decision

34. I have found no fault by the Council, the Trust or the CCG about their roles in Mrs R’s CHC assessment.
35. There was fault by the Practice about its consideration of fast-track CHC funding. It has already accepted this fault and taken action to put right the systemic failings. A retrospective CHC review offered by the CCG will address any financial injustice should this apply. I have therefore completed my investigation.

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Investigator's decision on behalf of the Ombudsman